TO THE EDITOR—Endocarditis is a common complication of bacteraemia caused by Streptococcus bovis (S. bovis) [1]. S. bovis is the 5th leading cause of endocarditis [2], although its incidence varies significantly from one geographical region to the another [3]. Between 6% and 16% of cases of endocarditis due to S. bovis have prosthetic valve involvement (PVE) [1, 3–7]. Although a few cases have been published [8, 9], there are no large series that analyze this type of infection. We present 23 cases of PVE due to S. bovis diagnosed in our hospital between 1988 and 2015. The endocarditis criteria and the method for identifying it have been previously described [10]. These 23 cases represented 20.5% of the 112

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Prosthetic Endocarditis Caused by Streptococcus bovis Group

Table 1. Differences Between Endocarditis Caused by S. bovis, Native and Prosthetic S. bovis Endocarditis

Native n = 89

Prosthetic n = 23

P Value

65.5 ± 14.2

74.5 ± 9.2

.001

93.2

82.6

NS

Age (mean ± SD) Sex (% male) Valve affected: Mitral

23 (25.8%)

5 (21.7%)

NS

Aortic Multiple valve

30 (33.7%) 28 (31.4%)

15 (65.2%) 2 (8.6%)

.0012 .0398

Right side valve Duration symptoms (days) Fever

1 (1.1%) 58.3 ± 56.7 7 (83.1%)

0 29.7 ± 23.1 18 (78.2%)

NS .001 NS

19 (21.3%)

2 (8.6%)

NS

42 (47.1%) 7 (7.8%)

6 (26%) 7 (30.4%)

.0467 .0000

Colon tumour

56 (62.9%)

15 (65.2%)

NS

Comorbidity: Diabetes mellitus

14 (15.7%)

Cirrhosis Noncolonic cancer No. blood cultures (+) per patient

7 (30.4%)

NS

0

NS

10 (11.2%) 4.7 ± 1.9

4 (17.3%) 4.4 ± 1.9

NS NS

86 (96.6%) 2 (2.2%)

17 (73.9%) 5 (21.7%)

.0017 .0031

6 (6.7%)

Note Potential conflicts of interest. All authors: No potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Species S. gallolyticus subsp. gallolyticus S. infantarius S. pasteurianus subsp. pasteurianus Cardiac surgery Mortality

1 (1.1%)

1 (4.3%)

NS

11 (12.3%) 11 (12.5%)

2 (8.6%) 1 (4.3%)

NS NS

10 (11.2%) 12 (15.6%)

0 3 (13%)

NS NS

0

NS

María José García-País,1 Ramón Rabuñal,1 María Pilar Alonso,2 and Juan Corredoira1 1

Infectious Disease Unit, and 2Department of Clinical Microbiology, Hospital Universitario Lucus Augusti, Lugo, Spain

Follow-up (first year) Late cardiac surgery Late mortality Relapses

0

The bold values are those with statistical significance. Abbreviations: NS, not specified; SD, standard deviation.

cases of endocarditis due to S. bovis and 21.1% of PVE cases. A significant increase in cases has occurred in recent years. Thus, although there were no such cases among the 24 cases of endocarditis due to S. bovis from 1988 to 2001, there were 23 cases out of 88 (26.1%) (P < .02) from 2002 to 2015. This increase coincided with an increase in valve surgery in our area during this period. A total of 82.6% (19/23) of the cases occurred more than 1 year after the prosthesis was implanted (mean 75 ± 63.6 months). S. bovis was the second leading cause of PVE after staphylococci (38 cases), and the leading cause of late PVE. Of the 103 cases of endocarditis due to S. bovis biotype I (S. gallolyticus subsp. gallolyticus), 17 were

PVE (16.5%), whereas 6 of the 9 (66.6%) cases caused by S. bovis biotype II were PVE [5 due to S. bovis biotype II/1 (S. infantarius) and 1 due to S. bovis biotype II/ 2 (S. pasteurianus); P < .001]. The characteristics of these cases of endocarditis are listed in Table 1. The patients with PVE due to S. bovis had a higher mean age, greater aortic involvement, and more paravalvular complications, whereas those with native valve endocarditis had longer lasting symptoms, greater multivalvular involvement, and a higher rate of embolisms. However, there were no significant differences in terms of the presence of heart failure, mortality, and the need for surgery, both during the episode and at 1 year.

References 1. Corredoira J, Alonso MP, Coira A, et al. Characteristics of Streptococcus bovis endocarditis its differences with Streptococcus viridans endocarditis. Eur J Clin Microbiol Infect Dis 2008; 27:285–91. 2. Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med 2009; 9:463–73. 3. Hoen B, Chirouze C, Cabell CH, et al. Emergence of endocarditis due to group D streptococci: findings derived from the merged database of the International Collaboration on Endocarditis. Eur J Clin Microbiol Infect Dis 2005; 24:12–6. 4. Giannitsioti E, Chirouze C, Bouvet A, et al. Characteristics and regional variations of group D streptococcal endocarditis in France. Clin Microbiol Infect 2007; 13:770–6. 5. Moellering R, Watson B, Kunz L. Endocarditis due to group D Streptococci: comparison of disease caused by Streptococcus bovis with that produced by the enterococci. Am J Med 1974; 57:239–50. 6. Pergola V, di Salvo G, Habib G, Avierinos J, Philip E, Vailloud J. Comparison of clinical and echocardiographic characteristics of Streptococcus bovis endocarditis with caused

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Heart failure Embolisms Paravalvular complication

In conclusion, PVE due to S. bovis is a condition that appears to be growing in prevalence in our center and is only exceeded by staphylococci in the number of cases. PVE due to S. bovis do not have more complications or a poorer prognosis than those with native valve endocarditis. Our data suggest that endocarditis due to the biotype II has a greater propensity to affect the prosthesis than S. gallolyticus subsp. gallolyticus. Studies with larger series are needed to confirm these findings.

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Correspondence: Ramón Rabuñal, MD, PhD, Infectious Disease Unit, Hospital Universitario Lucus Augusti, Avda. Dr. Ulises Romero, n° 1. 27003, Lugo, Spain ([email protected]). Clinical Infectious Diseases® 2015;61(7):1204–6 © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/civ541

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by other pathogens. Am J Cardiol 2001; 88:871–5. Ballet M, Gevigney G, Gare J, Delahaye F, Etienne J, Delhaye J. Infective endocarditis due to Streptococcus bovis: a report of 53 cases. Eur Heart J 1995; 16:1975–80. Warren J, Louie KG, Greenspahn BR, Karunaratne B. S. bovis endocarditis on a prosthetic heart valve, with a colonic neoplasm. N Engl J M 1981; 20:1239–40. Kenzaka T, Nishimura Y. Three-dimensional transoesophageal echocardiography for the diagnosis of prosthetic valve endocarditis. BMJ Case Rep 2014; doi:10.1136/bcr-2014-203592. Corredoira J, García Garrote F, Rabuñal R, et al. Association between bacteraemia due to Streptococcus gallolyticus subsp. gallolyticus (S. bovis I) and colorectal cancer: a case-control study. Clin Infect Dis 2012; 55: 491–6.

Prosthetic Endocarditis Caused by Streptococcus bovis Group.

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